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id=\u0022aff-2\u0022 name=\u0022aff-2\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E2\u003C\/sup\u003ESchool of Public Health, Makerere University, \u003Cspan class=\u0022addr-line\u0022\u003EKampala\u003C\/span\u003E, Uganda\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-3\u0022 name=\u0022aff-3\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E3\u003C\/sup\u003ESchool of Public Health, University of Ghana, \u003Cspan class=\u0022addr-line\u0022\u003ELegon\u003C\/span\u003E, Ghana\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-4\u0022 name=\u0022aff-4\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E4\u003C\/sup\u003EInstitute of Development Studies, University of Dar Es Salaam, \u003Cspan class=\u0022addr-line\u0022\u003EDar Es Salaam\u003C\/span\u003E, United Republic of Tanzania\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-5\u0022 name=\u0022aff-5\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E5\u003C\/sup\u003ESwiss Tropical and Public Health Institute, University of Basel, \u003Cspan class=\u0022addr-line\u0022\u003EBasel\u003C\/span\u003E, Switzerland\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-6\u0022 name=\u0022aff-6\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E6\u003C\/sup\u003EDepartment of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK\u003C\/address\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022corresp-list\u0022\u003E\u003Cli class=\u0022corresp\u0022 id=\u0022corresp-1\u0022\u003E\u003Cspan class=\u0022corresp-label\u0022\u003ECorrespondence to\u003C\/span\u003E Mrs C Mshelia; \u003Cspan class=\u0022em-link\u0022\u003E\u003Cspan class=\u0022em-addr\u0022\u003Ec.mshelia{at}leeds.ac.uk\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article abstract-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003EAbstract\u003C\/h2\u003E\u003Cdiv id=\u0022sec-1\u0022 class=\u0022subsection\u0022\u003E\n\n\u003Cp id=\u0022p-2\u0022\u003E\u003Cstrong\u003EIntroduction\u003C\/strong\u003E The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel \u003Cem\u003Eand\u003C\/em\u003E by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv id=\u0022sec-2\u0022 class=\u0022subsection\u0022\u003E\n\n\u003Cp id=\u0022p-3\u0022\u003E\u003Cstrong\u003EMethods\u003C\/strong\u003E The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts\u00a0each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, \u2018bundles\u2019 of HR\/HS strategies that are feasible within the context and affordable within the districts\u2019 budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR\/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv id=\u0022sec-3\u0022 class=\u0022subsection\u0022\u003E\n\n\u003Cp id=\u0022p-4\u0022\u003E\u003Cstrong\u003EDiscussion\u003C\/strong\u003E Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022license\u0022 id=\u0022license-1\u0022\u003E\u003Cp id=\u0022p-1\u0022\u003EThis is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: \u003Ca href=\u0022http:\/\/creativecommons.org\/licenses\/by-nc\/3.0\/\u0022\u003Ehttp:\/\/creativecommons.org\/licenses\/by-nc\/3.0\/\u003C\/a\u003E\u003C\/p\u003E\u003C\/div\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-snippet pane-jnl-template-bmjj-art-middle-ad oas-ads oas-ads-mid pull-right\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022snippet jnl-template-bmjj-art-middle-ad\u0022 id=\u0022jnl-template-bmjj-art-middle-ad\u0022\u003E\n \n \n \u003Cdiv class=\u0022snippet-content\u0022\u003E\n \u003Cdiv id=\u0022oas_Middle1\u0022\u003E\u003Cscript type=\u0022text\/javascript\u0022\u003Eoas_tag.loadAd(\u0022Middle1\u0022);\u003C\/script\u003E\u003C\/div\u003E\n \u003C\/div\u003E\n\n\u003C\/div\u003E\n \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-custom pane-1\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cp\u003E\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1136\/bmjopen-2013-003625\u0022 target=\u0022_new\u0022\u003Ehttp:\/\/dx.doi.org\/10.1136\/bmjopen-2013-003625\u003C\/a\u003E\u003C\/p\u003E\n \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-altmetrics\u0022 \u003E\n \n \u003Ch2 class=\u0022pane-title\u0022\u003EStatistics from Altmetric.com\u003C\/h2\u003E\n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv data-badge-details=\u0022right\u0022 data-badge-type=\u0022medium-donut\u0022 data-doi=\u002210.1136\/bmjopen-2013-003625\u0022 data-hide-no-mentions=\u0022true\u0022 class=\u0022altmetric-embed\u0022\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-bmjj-jumplinks\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-list-wrapper\u0022\u003E\u003Cdiv class=\u0022highwire-list\u0022\u003E\u003Cul\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022boxed-text\u0022 id=\u0022boxed-text-1\u0022\u003E\n\u003Ch3\u003EArticle summary\u003C\/h3\u003E\n\u003Cdiv id=\u0022sec-4\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003EArticle focus\u003C\/h4\u003E\n\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n\u003Cp id=\u0022p-5\u0022\u003EThere is a need for more research into how best to improve the performance of the existing health workforce in sub-Saharan Africa (SSA). However, the complexity of health systems (HS) and wider environment requires an understanding of how health worker performance can be improved in the real and complex world facing health managers and decision-makers in SSA.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n\u003Cp id=\u0022p-6\u0022\u003EThe dissemination of this research protocol is intended to generate interest in the PERFORM project and, more importantly, stimulate discussion on the use of action research (AR) to improve health workforce performance within complex health systems in low-income and middle-income countries.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-5\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003EKey messages\u003C\/h4\u003E\n\u003Cul class=\u0022list-unord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n\u003Cp id=\u0022p-7\u0022\u003EUsing AR to design and evaluate the effects of interventions to strengthen district health management and improve health workforce performance should encourage ownership of the results by the district health managers and ensure the sustainability of the interventions even after the project has ended.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n\u003Cp id=\u0022p-8\u0022\u003EKey challenges faced during the development of the methodology are: the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining anonymity and confidentiality of study participants as well as how to record the processes during the study.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-6\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003EStrengths and limitations of this study\u003C\/h4\u003E\n\u003Cul class=\u0022list-unord \u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n\u003Cp id=\u0022p-9\u0022\u003EComparing the intervention effects across the nine unique study sites is likely to be methodologically complex. While this is a strength of the study, it requires a combination of different methodological expertise.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n\u003Cp id=\u0022p-10\u0022\u003EThis study will generate new knowledge on \u2018what HR\/HS interventions work best for whom and in which contexts\u2019 and how district health managers can be supported to do their work better.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section intro\u0022 id=\u0022sec-7\u0022\u003E\n\u003Ch2\u003EIntroduction\u003C\/h2\u003E\n\u003Cp id=\u0022p-11\u0022\u003EThe single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce.\u003Ca id=\u0022xref-ref-1-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-1\u0022\u003E1\u003C\/a\u003E \u003Cspan class=\u0022xref-sep\u0022\u003E,\u003C\/span\u003E\u003Ca id=\u0022xref-ref-2-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-2\u0022\u003E2\u003C\/a\u003E This deficit in health workforce capacity needs to be addressed both by training more new health personnel \u003Cem\u003Eand\u003C\/em\u003E by improving the performance of the existing and future health workforce. However, simply increasing the number of health workers or improving workforce performance will not necessarily result in the improvement of health-related processes and outcomes unless the organisational context provides an enabling environment in which to carry out the healthcare activities.\u003C\/p\u003E\n\u003Cp id=\u0022p-12\u0022\u003EMuch emphasis in research and development has been placed on training more new health personnel\u003Ca id=\u0022xref-ref-3-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-3\u0022\u003E3\u003C\/a\u003E \u003Cspan class=\u0022xref-sep\u0022\u003E,\u003C\/span\u003E\u003Ca id=\u0022xref-ref-4-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-4\u0022\u003E4\u003C\/a\u003E and less on strategies for improving workforce performance.\u003Ca id=\u0022xref-ref-5-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-5\u0022\u003E5\u003C\/a\u003E WHO describes the dimensions of a well-performing workforce as availability, competence, responsiveness and productivity.\u003Ca id=\u0022xref-ref-6-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-6\u0022\u003E6\u003C\/a\u003E Vujicic and Ohiri\u003Ca id=\u0022xref-ref-7-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-7\u0022\u003E7\u003C\/a\u003E add quality of care and highlight the importance of absenteeism as a determinant of availability. We understand performance management as the process of creating a work environment or setting in which people are enabled to perform to the best of their abilities. While human resource (HR) management is understood as the process of facilitating and improving the performance of the collaborators by building a conducive work environment and providing maximum opportunities to the collaborators for participating in the organisational planning and decision-making process, we are specifically interested in the interactions of these processes with the broader health systems (HS) functioning.\u003C\/p\u003E\n\u003Cp id=\u0022p-13\u0022\u003EIn 2007, WHO introduced a model of six interdependent HS building blocks including HRs and the need for integrated strategic responses to challenges.\u003Ca id=\u0022xref-ref-8-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-8\u0022\u003E8\u003C\/a\u003E De Savigny and Adams\u003Ca id=\u0022xref-ref-9-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-9\u0022\u003E9\u003C\/a\u003E further developed the concept of health systems thinking in health systems strengthening and, more recently, the concept of complex adaptive systems has been described to highlight the complex nature of health systems.\u003Ca id=\u0022xref-ref-10-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-10\u0022\u003E10\u003C\/a\u003E \u003Cspan class=\u0022xref-sep\u0022\u003E,\u003C\/span\u003E\u003Ca id=\u0022xref-ref-11-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-11\u0022\u003E11\u003C\/a\u003E Projects with complex social interventions can adopt a realistic approach: \u201cwhat works for whom, in what circumstances, in what respects, and how?\u201d (p.V)\u003Ca id=\u0022xref-ref-12-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-12\u0022\u003E12\u003C\/a\u003E and recognise that \u201cevery intervention, from the simplest to the most complex, has an effect on the overall system, and the overall system has an effect on every intervention\u201d (p.19).\u003Ca id=\u0022xref-ref-9-2\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-9\u0022\u003E9\u003C\/a\u003E The concept of systems thinking is also found in the mainstream HR management literature which recognises the complex interactions between different HR management strategies, the methods of implementation and the wider HS context.\u003Ca id=\u0022xref-ref-13-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-13\u0022\u003E13\u003C\/a\u003E \u003Cspan class=\u0022xref-sep\u0022\u003E,\u003C\/span\u003E\u003Ca id=\u0022xref-ref-14-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-14\u0022\u003E14\u003C\/a\u003E For example, the pay-for-performance of health workers in maternity care may be combined with learner-directed training, changes in processes (eg, consultation), supplies (eg, medicines), equipment (eg, laboratory) and infrastructure (eg, facilities). Therefore an integrated set, or a \u2018bundle\u2019, of HR and HS strategies can address complex areas such as improved workforce performance.\u003Ca id=\u0022xref-ref-15-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-15\u0022\u003E15\u201317\u003C\/a\u003E A pay-for-performance initiative in one area may also lead to unintended effects such as the neglect of other service delivery areas, because health personnel are distracted from their essential duties.\u003C\/p\u003E\n\u003Cp id=\u0022p-14\u0022\u003EThe ability to adopt a systems approach\u2014combining an integrated set of HR and complementary HS strategies with the aim of achieving synergies and avoiding negative unintended consequences\u2014is only possible if managers have adequate room for manoeuvre of what Bossert and Beauvais\u003Ca id=\u0022xref-ref-18-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-18\u0022\u003E18\u003C\/a\u003E refer to as \u2018decision space\u2019. The increasing HS decentralisation of planning and management authority to lower levels and, in particular, to districts in SSA can make this space available to managers.\u003C\/p\u003E\n\u003Cp id=\u0022p-15\u0022\u003ELocal health managers need to learn how to effectively use the available decision space. Owing to the complexity of all the influences, including resource constraints, to be considered, this may be best learnt through Action Research (AR) on the job\u003Ca id=\u0022xref-ref-19-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-19\u0022\u003E19\u003C\/a\u003E as a form of management development (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003Efigure 1\u003C\/a\u003E).\u003C\/p\u003E\n\u003Cdiv id=\u0022F1\u0022 class=\u0022fig odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Action research cycle.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1733393984\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Action research cycle.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure\u0026#xA0;1\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F1.medium.gif\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure\u0026#xA0;1\u0022 src=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F1.medium.gif\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure\u0026#xA0;1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/82636\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure\u00a01\u003C\/span\u003E \u003Cp id=\u0022p-16\u0022 class=\u0022first-child\u0022\u003EAction research cycle.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-17\u0022\u003EThe PERFORM project, funded by the European Commission FP7 Framework, aims to enhance our understanding of how health workforce performance at the district level in three African countries can be improved and how AR as an approach can strengthen health management capacity. We are further interested in the relations between improved HR performance and its interactions with HS performance.\u003C\/p\u003E\n\u003Cdiv id=\u0022sec-8\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EAR in PERFORM\u003C\/h3\u003E\n\u003Cp id=\u0022p-18\u0022\u003EAR has been defined as \u201can enquiry which is conducted by a group on a problem which is of interest to them. Its aim is twofold; to improve practice and to generate knowledge about the processes and strategies that work best to create that improvement.\u201d\u003Ca id=\u0022xref-ref-20-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-20\u0022\u003E20\u003C\/a\u003E \u003Cspan class=\u0022xref-sep\u0022\u003E,\u003C\/span\u003E\u003Ca id=\u0022xref-ref-21-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-21\u0022\u003E21\u003C\/a\u003E\u003C\/p\u003E\n\u003Cp id=\u0022p-19\u0022\u003ELewin\u003Ca id=\u0022xref-ref-22-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-22\u0022\u003E22\u003C\/a\u003E is often credited with first describing the AR cycle. The cycle has further been described as a spiral or similar to an intertwined Russian wedding ring\u003Ca id=\u0022xref-ref-23-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-23\u0022\u003E23\u003C\/a\u003E as the complexity of the cycles of intervention and evaluation deepens.\u003C\/p\u003E\n\u003Cp\u003EIn contrast to a top-down research approach where project design and implementation are directed by outsiders, in AR studies, the people who are closest to the problem, in this case the district health management teams (DHMTs), will lead on planning, implementation, observation, reflection and the redefinition of the activities in the study. The country research teams (CRTs) will support the DHMTs and can ask for peer advice from the paired European partner (EP). The DHMTs will continuously work through systematic cycles of planning, acting, observing and reflecting to\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-4\u0022\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n\u003Cp id=\u0022p-21\u0022\u003EDescribe and analyse the initial and changing HR and HS situation they face (eg, analysing the evidence available to them).\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n\u003Cp id=\u0022p-22\u0022\u003EIdentify and plan strategies to improve the situation or problem (eg, using the literature to select interventions they can implement within their budget).\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n\u003Cp id=\u0022p-23\u0022\u003EImplement the changes needed (eg, through decisions taken during DHMT meetings).\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n\u003Cp id=\u0022p-24\u0022\u003EObserve and record the effects (eg, through monitoring and evaluation).\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\n\u003Cp id=\u0022p-25\u0022\u003EExplain and reflect on the processes and effects of changes made (eg, discuss identified outcomes during DHMT meetings).\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003Cp id=\u0022p-26\u0022\u003EThe purpose of this paper is to disseminate the methodology for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. We start by outlining the project\u0027s aim and objectives. We proceed to describe the project setting and partners, outline the research design and finally conclude with a reflection on the lessons learnt from this experience.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section methods\u0022 id=\u0022sec-9\u0022\u003E\n\u003Ch2\u003EMethods\u003C\/h2\u003E\n\u003Cdiv id=\u0022sec-10\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EProject aim and objectives\u003C\/h3\u003E\n\u003Cp id=\u0022p-27\u0022\u003EThe aim of the PERFORM project was therefore to identify ways of strengthening decentralised management to address health workforce inadequacies by improving health workforce performance in SSA. It seeks to answer the following key questions: how effective is AR for management strengthening in the context of decentralised managerial authority? And, what bundles of HR\/HS strategies help improve workforce performance, for whom and in what contexts?\u003C\/p\u003E\n\u003Cp\u003EIn addition to developing new knowledge, the specific research objectives are:\n\u003C\/p\u003E\u003Col class=\u0022list-ord \u0022 id=\u0022list-5\u0022\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\n\u003Cp id=\u0022p-29\u0022\u003ETo support health managers to carry out a situation analysis on the health workforce, with a particular focus on performance, in the study districts.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-13\u0022\u003E\n\u003Cp\u003ETo develop and test context-specific management strengthening processes, focused on improving workforce performance, which will\n\u003C\/p\u003E\u003Col class=\u0022list-alphaupper \u0022 id=\u0022list-6\u0022\u003E\u003Cli id=\u0022list-item-14\u0022\u003E\n\u003Cp id=\u0022p-31\u0022\u003EIdentify areas of health workforce performance to be improved;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-15\u0022\u003E\n\u003Cp id=\u0022p-32\u0022\u003EImplementing integrated HR and HS strategies feasible within the existing context, to improve health workforce performance;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-16\u0022\u003E\n\u003Cp id=\u0022p-33\u0022\u003EMonitor the implementation of strategies and evaluate the intermediate processes and impact on health workforce performance and the wider HS.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-17\u0022\u003E\n\u003Cp\u003ETo conduct comparative analyses across districts and countries of\n\u003C\/p\u003E\u003Col class=\u0022list-alphaupper \u0022 id=\u0022list-7\u0022\u003E\u003Cli id=\u0022list-item-18\u0022\u003E\n\u003Cp id=\u0022p-35\u0022\u003EThe management strengthening intervention to support improved workforce performance;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-19\u0022\u003E\n\u003Cp id=\u0022p-36\u0022\u003EProcesses of implementing the integrated HR and HS strategies and the intended and unintended effects on health workforce performance and the wider HS.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-20\u0022\u003E\n\u003Cp id=\u0022p-37\u0022\u003ETo provide ongoing communication of the research process, findings and conclusions, as well as to improve the research capacity of partners on integrated approaches to workforce performance improvement and contribute to strengthening capacities of decentralised management of district HSs.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ol\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-11\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EProject setting\u003C\/h3\u003E\n\u003Cp id=\u0022p-38\u0022\u003EThe project will work at the district level in Ghana, Tanzania and Uganda. These three countries were selected because they have decentralised health systems where managers have adequate potential \u2018decision space\u2019\u003Ca id=\u0022xref-ref-18-2\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-18\u0022\u003E18\u003C\/a\u003E to address the problems of poor performance of the health workforce.\u003C\/p\u003E\n\u003Cp id=\u0022p-39\u0022\u003EThree districts in each country have been selected for this study using two broad predefined criteria. First, owing to the collaborative nature of the project, it was important to have a motivated and reasonably staffed DHMT with which to work. A second criterion was the inclusion of different district contexts including a mix of rural and urban as well as those with good and poor overall performance. As this was not an experimental study, no control districts were selected. However, information about wider contextual changes to inform the impact assessment of the interventions will be captured.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-12\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EPartners\u003C\/h3\u003E\n\u003Cp id=\u0022p-40\u0022\u003ESix partner institutions make up the PERFORM consortium\u2014three are based in Africa and three in Europe. Each partner from an African country (also referred to as CRTs) is paired with an EP (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003Etable 1\u003C\/a\u003E).\u003C\/p\u003E\n\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T1\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/82641\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/82641\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable\u00a01\u003C\/span\u003E \u003Cp id=\u0022p-41\u0022 class=\u0022first-child\u0022\u003EPaired partners\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-42\u0022\u003EThe DHMTs are regarded as coresearchers in the project; rather than have the research conducted \u003Cem\u003Eon\u003C\/em\u003E them, the research is conducted \u003Cem\u003Ewith\u003C\/em\u003E and \u003Cem\u003Eby\u003C\/em\u003E them. They will be involved in collecting and analysing data throughout the project as well as leading and participating in each phase of the AR cycle.\u003C\/p\u003E\n\u003Cp id=\u0022p-43\u0022\u003EThe CRTs will act as facilitators, supporting the DHMTs in identifying appropriate research tools and analysis methods, problem analysis and strategy development as well as facilitating reflection among the DHMTs on how to maximise the effectiveness of the interventions. Specific capabilities and strengths will differ from one DHMT to another, and therefore, ultimately, there will be room for negotiation of roles between the DHMTs and the CRTs.\u003C\/p\u003E\n\u003Cp id=\u0022p-44\u0022\u003EThe EPs as part of the paired partnership will provide support and offer research advice to their African pairs and are also expected to attend all national workshops held by their paired African partner. The University of Leeds is offering a methodology help desk to all partners during the implementation phase.\u003C\/p\u003E\n\u003Cp id=\u0022p-45\u0022\u003EIn a unique opportunity to transfer knowledge and skills in both directions and to document a reflection-action process which will be hopefully embedded in the routine management practices at the district level, PERFORM has brought together DHMTs and researchers from Africa and researchers from Europe. PERFORM provides opportunities for intercountry collaboration and learning.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-13\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EResearch design\u003C\/h3\u003E\n\u003Cp id=\u0022p-46\u0022\u003EThis project will use AR to enhance understanding of how and under what conditions strengthening of district health management can improve health workforce performance. A systems approach using an integrated set of HR and other HS strategies that are feasible within the context and affordable within the DHMT budget will be used by district level managers through an AR approach (see \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003Efigure 2\u003C\/a\u003E) to strengthen district management in order to improve health workforce performance.\u003C\/p\u003E\n\u003Cdiv id=\u0022F2\u0022 class=\u0022fig odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Overview of the research concept.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1733393984\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Overview of the research concept.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure\u0026#xA0;2\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F2.medium.gif\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure\u0026#xA0;2\u0022 src=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F2.medium.gif\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure\u0026#xA0;2\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/82638\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure\u00a02\u003C\/span\u003E \u003Cp id=\u0022p-47\u0022 class=\u0022first-child\u0022\u003EOverview of the research concept.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-48\u0022\u003EThrough the AR cycles, the DHMTs, with the assistance of the CRTs, will evaluate the success of these HR\/HS bundles to improve district workforce performance. The DHMTs, CRTs and EPs will reflect continually throughout the project and compare baseline and end-line data to assess the effectiveness of the use of AR in strengthening district management processes.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-14\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EProject timeline\u003C\/h3\u003E\n\u003Cp id=\u0022p-49\u0022\u003EThe project started in September 2011 and will last a total of 48\u2005months as shown in \u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003Efigure 3\u003C\/a\u003E. It is split into three phases.\u003C\/p\u003E\n\u003Cdiv id=\u0022F3\u0022 class=\u0022fig odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Project timeline.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1733393984\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Project timeline.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure\u0026#xA0;3\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F3.medium.gif\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure\u0026#xA0;3\u0022 src=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F3.medium.gif\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure\u0026#xA0;3\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/bmjopen\/3\/8\/e003625\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/82640\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure\u00a03\u003C\/span\u003E \u003Cp id=\u0022p-50\u0022 class=\u0022first-child\u0022\u003EProject timeline.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-51\u0022\u003E\u003Cem\u003EPhase 1\u003C\/em\u003E involves project start-up, district selection and methodology development. During phase 1, study districts will be selected in each country and the research methodology developed and finalised in collaboration with local and national stakeholders. The methodology will include agreements on the indicators for which data will be collected and the development of specific data collection tools, for subsequent adaptation in each country. The methodology will be updated periodically as the project progresses, based on need and the reflections of the PERFORM research team.\u003C\/p\u003E\n\u003Cp id=\u0022p-52\u0022\u003E\u003Cem\u003EPhase 2\u003C\/em\u003E is the implementation phase of the project and will last about 24\u2005months. During the first 9\u2005months of this period, each DHMT will be supported to undertake a situation analysis of the state of the health workforce in their district, the DHMT management capacity including their decision-making space as well as the wider HS and the contextual environment. The findings of the situation analysis will be reviewed during National workshop 1 involving the members of each DHMT, relevant stakeholders such as members of the regional health management team and supported by the respective CRT and EP. At consortium workshop 2, CRTs and EPs will discuss the findings of the situation analyses and possible HR\/HS bundles to address the problem areas in each district explored. Following this workshop and supported by the CRTs, the DHMTs in each district will go on to select relevant HR\/HS bundles to address their respective problems. Each DHMT will have the freedom to choose which problems to work on. This is primarily to foster ownership for the process and the results. Each DHMT will be encouraged to integrate a plan for implementing and monitoring the effects of the bundles into their annual district health plans; this includes identification of what data to collect, as well as the methods and timing for the data collection.\u003C\/p\u003E\n\u003Cp id=\u0022p-53\u0022\u003EThe selected HR\/HS bundles will be implemented in each district by the DHMT. Using the AR cycles, the effects of the actions of the DHMTs will be observed and reflected on by the DHMTs. In the light of this, elements of the HR\/HS bundles may change or new ones may be added during the implementation period. At consortium workshop 3, CRTs and EPs will review the progress of the HR\/HS bundles in each district and plan for comparative analysis. The effects of the HR\/HS bundles on the health workforce and service delivery indicators will be evaluated in each district. At the end of this phase, the DHMTs will undertake another situation analysis which will form part of the evaluation of the HR\/HS bundles and will serve as a comparison with the baseline dataset from the initial situational analysis. Following this, the DHMTs and CRTs will meet at National workshop 3 to discuss and share the findings across the three districts.\u003C\/p\u003E\n\u003Cp id=\u0022p-54\u0022\u003EThe main focus of \u003Cem\u003Ephase 3\u003C\/em\u003E is the intracountry and intercountry comparative analysis of the extent to which, and under what conditions, the implemented interventions work well for strengthening the management skills of DHMTs and improving the health workforce performance. Furthermore, the content of strategies and their intended and unintended effects will be explored\u2014both on the workforce performance and on the wider health system. At consortium workshop 4, all partners will meet to review the preliminary findings from the comparative analysis. Following this meeting, a small amount of additional data may be collected. The analysis will then be completed and the results compiled into a research report.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-15\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EData collection\u003C\/h3\u003E\n\u003Cp\u003EQuantitative and qualitative data collection methods will be used during the project. Each DHMT can choose the methods they wish to use depending on the action being assessed within the AR cycle. Several data sources have been identified\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-8\u0022\u003E\u003Cli id=\u0022list-item-21\u0022\u003E\n\u003Cp id=\u0022p-56\u0022\u003ERoutine data from Health Management Information Systems;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-22\u0022\u003E\n\u003Cp id=\u0022p-57\u0022\u003EA district questionnaire developed specifically for this project;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-23\u0022\u003E\n\u003Cp id=\u0022p-58\u0022\u003EKey informant interviews and focus group discussions;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-24\u0022\u003E\n\u003Cp id=\u0022p-59\u0022\u003EObservation of management processes;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-25\u0022\u003E\n\u003Cp id=\u0022p-60\u0022\u003EDocument review of official reports and minutes of meetings.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003Cp id=\u0022p-61\u0022\u003EWhere possible, routine data will be used to assess the effectiveness of the strategies, with the aim being to support DHMTs in the use of routinely available data to inform their planning and decision-making. This is seen as a more sustainable approach to strengthening the management capacity of DHMT. Data collection tools have been adapted to suit the context and needs in each country. The processes and learning from observations are being recorded by DHMTs in learning histories with reflection supported by the CRTs.\u003C\/p\u003E\n\u003Cp id=\u0022p-62\u0022\u003EThe CRTs will provide research advice to the DHMTs during data collection and also take part in collecting and analysing data where necessary.\u003C\/p\u003E\n\u003Cdiv id=\u0022sec-16\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003ESituation analysis\u003C\/h4\u003E\n\u003Cp\u003EThe purpose of the initial situation analysis is to serve as the baseline for the project as well as to inform the subsequent AR cycles in each district. It is being carried out in a two step process:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-9\u0022\u003E\u003Cli id=\u0022list-item-26\u0022\u003E\n\u003Cp id=\u0022p-64\u0022\u003EThe first step is common to all study sites: data on basic information on the health workforce, DHMT, HS and the local and national context will be collected. This information will be used by the CRTs to prepare a report for the before\/after comparative analysis in and between all districts.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-27\u0022\u003E\n\u003Cp id=\u0022p-65\u0022\u003EThe second step is specific to each study site and will focus on particular issues or problems emerging in step 1, for example, lack of training opportunities. These will become part of the first AR cycle in the district. A toolkit of data collection methods is available for the DHMTs to use in consultation with the CRTs, and to adapt to the district context, and includes: key informant interviews, focus group discussions, surveys, observations of management processes and document reviews. CRTs are providing advice on research strategies.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-17\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003EAR cycles\u003C\/h4\u003E\n\u003Cp id=\u0022p-66\u0022\u003EIn the observation and reflection parts of the AR cycle, data will be collected to record the implementation process, the observed effects of the implemented changes and the reflection and learning which are taking place. The DHMTs, with support from the CRTs, are selecting the methods to collect this data.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-18\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003EFinal situation analysis\u003C\/h4\u003E\n\u003Cp id=\u0022p-67\u0022\u003EThis will take place after the implementation of the HR\/HS bundles is complete. The data collected will be the same as that collected during the initial situation analysis.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-19\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003EEvaluation of intervention effects\u003C\/h4\u003E\n\u003Cp id=\u0022p-68\u0022\u003EIn order to evaluate the effectiveness of the selected HR\/HS bundles as well as their effects, it is necessary to collect data on outputs relevant to the intervention and analyse these data. It is planned that this will take place on an ongoing basis as part of the AR cycle. The data collection method to be used for this will be decided by the DHMTs and CRTs.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-20\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch4\u003EEvaluation of the DHMT strengthening process\u003C\/h4\u003E\n\u003Cp id=\u0022p-69\u0022\u003EIn order to evaluate the effectiveness of the DHMT strengthening process, it is necessary to have the above information on the bundles, analyse the learning histories in each district and organise a focus group and individual interviews with DHMT members.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-21\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EData analysis\u003C\/h3\u003E\n\u003Cp\u003ESeveral analyses will be undertaken\n\u003C\/p\u003E\u003Col class=\u0022list-ord \u0022 id=\u0022list-10\u0022\u003E\u003Cli id=\u0022list-item-28\u0022\u003E\n\u003Cp id=\u0022p-71\u0022\u003ESituational analysis before and after the implementation of HR\/HS bundles aimed at capturing baseline information on key indicators in the districts.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-29\u0022\u003E\n\u003Cp id=\u0022p-72\u0022\u003EComparative analyses focused on measuring and recording the differences over time and between geographical regions as the project progresses.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-30\u0022\u003E\n\u003Cp id=\u0022p-73\u0022\u003EOngoing analysis of the effects of implemented HR\/HS bundles.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ol\u003E\n\u003Cp id=\u0022p-74\u0022\u003EGeneric indicators and measurements will be used to describe each study site. The choice of indicators and outcomes on selected problem areas is made by the DHMTs with agreement and support from the CRTs and EPs. The analysis of the data obtained during the project follows the AR approach. This means that while conventional qualitative and quantitative analysis methods are used, the process of the analysis aims to be participatory, with DHMTs discussing and reflecting on how to analyse quantitative data and the interpretations of qualitative data.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003Cdiv id=\u0022sec-22\u0022 class=\u0022subsection\u0022\u003E\n\u003Ch3\u003EEthics\u003C\/h3\u003E\n\u003Cp id=\u0022p-75\u0022\u003EThe study protocol was approved by the appropriate Institutional Review Boards in Ghana, Tanzania and Uganda. In addition, ethics approval was also obtained from the Institutional Review Boards of the Liverpool School of Tropical Medicine (project coordinators) and the University of Leeds (project methodology lead).\u003C\/p\u003E\n\u003Cp id=\u0022p-76\u0022\u003EAll questionnaires and interview transcripts will be coded in order to protect the confidentiality of participants. No names or other identifying information of participants will be used in any results in order to ensure their anonymity.\u003C\/p\u003E\n\u003Cp id=\u0022p-77\u0022\u003EAll data collection tools such as the district questionnaire will be developed in English. Where English is not the official language such as in Tanzania, data collection tools will be translated by approved translators.\u003C\/p\u003E\n\u003Cp id=\u0022p-78\u0022\u003EAll participants will receive the project information sheet prior to being approached for written consent to participate in the project. Participants have the right to withdraw consent at any point during the project. All DHMTs have agreed to their participation as coresearchers and informants through a Memorandum of Understanding which was signed by the director of the DHMTs and the leader of the CRTs.\u003C\/p\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section discussion\u0022 id=\u0022sec-23\u0022\u003E\n\u003Ch2\u003EDiscussion\u003C\/h2\u003E\n\u003Cp id=\u0022p-79\u0022\u003EHaving summarised the research protocol, we now reflect on the key challenges encountered during the methodology development and discuss these alongside the lessons learnt for future similar studies.\u003C\/p\u003E\n\u003Cp\u003EDuring the development of the methodology, the consortium partners reflected on the application of the design and methods through face-to-face meetings, online discussions, email exchanges and workshops. These iterative reflections helped the team to adapt the methodology to the context of the three countries. The key lessons from this reflection include five broad issues.\n\u003C\/p\u003E\u003Col class=\u0022list-ord \u0022 id=\u0022list-11\u0022\u003E\u003Cli id=\u0022list-item-31\u0022\u003E\n\u003Cp id=\u0022p-81\u0022\u003E\u003Cem\u003EThe contexts in which we are working are constantly changing\u003C\/em\u003E; each district has different starting points and preferences for the issues they would like to address in their district. Hence, the researchers are faced with the challenge of, as it were, trying to \u2018jump on a moving train\u2019. Changes to key DHMT members such as the District Medical Officer due to transfers or study leave make it difficult to collaborate and plan ahead. Turnover of DHMT members means that new relationships have to be established, and it can take time for new members of staff to buy into the reflective AR process, though most DHMTs have around 10 members, so in most cases a critical mass will remain. The way out of this dilemma for the researchers has been to adopt a flexible approach regarding agreements and accommodate DHMTs constraints and priorities. While this approach may constrain the attainment of project objectives (given the limited time we have), we believe it is essential for fostering ownership and participation from the DHMTs.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-32\u0022\u003E\n\u003Cp id=\u0022p-82\u0022\u003EAR requires continuous substantial time inputs and strong commitment from all involved parties. DHMTs face multiple priorities and are faced with a substantial number of requests from internal and external bodies. For example, on a few occasions, DHMTs have been called away to attend other meetings and workshops during a scheduled PERFORM workshop. This, coupled with the changing context described previously, has created a challenge in time management for the DHMTs. This means that in order to achieve project goals and encourage continuity with the gains from the project, DHMTs need to integrate the project tasks within their routine work and duties. Each DHMT is integrating their selected HR\/HS bundles into their annual health plans. Also, the DHMTs have made a commitment to include the PERFORM project in the agenda for their routine meetings. This is likely to be challenging initially, as DHMTs adapt to a different way of doing things. However, in the long term, this may result in a more efficient use of their time and other resources.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-33\u0022\u003E\n\u003Cp id=\u0022p-83\u0022\u003E\u003Cem\u003EDeveloping the methodology for comparing what in essence are nine unique AR studies in a meaningful way has presented a challenge\u003C\/em\u003E. As it is not possible to know in advance which interventions each district will choose to implement, it is impossible to predetermine which outcomes will be measured and therefore compared across districts and countries. Our solution to this has been to compare the process of planning and implementing the interventions in each study district as well as comparing the extent to which each intervention achieves the desired effects. We plan to also compare how the effects of the interventions change DHMT management and health HR performance in the district.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-34\u0022\u003E\n\u003Cp id=\u0022p-84\u0022\u003E\u003Cem\u003EThe researchers have learnt that dealing with ethical issues such as maintaining confidentiality and anonymity of participants is not straightforward\u003C\/em\u003E. The difficulty stems from the fact that the DHMTs are coresearchers in this AR-based study, leading to two challenges. First, they are expected to also take part in data collection and analysis. This presents a dilemma where participants such as health facility staff or other local stakeholders express a view which portrays the DHMT, either as a group or individually, in less than favourable terms. In order to protect the confidentiality and anonymity of participants, the research team has adopted strict guidelines on obtaining, storing and referencing personal information to be adhered to by all researchers on the project, thus ensuring that only the necessary researchers have the ability to match the names of individuals to their responses. Second, it is quite likely that DHMTs will find out about difficulties in the other study districts in their country during joint meetings and workshops. The research team agreed to anonymise information and data as much as possible and remind each DHMT of their duties as researchers to keep certain information confidential and not share it outside the research group.\u003C\/p\u003E\n\u003Cp id=\u0022p-85\u0022\u003EThe PERFORM project will work towards introducing new ways of working in order to challenge and improve hierarchical HSs where gender and power interplay.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-35\u0022\u003E\n\u003Cp id=\u0022p-86\u0022\u003E\u003Cem\u003ERecording the processes and outcomes during the project is essential in order to facilitate learning\u003C\/em\u003E. Deciding how records are kept (ie, learning histories, journals or reflective logs, written or oral recordings) and who is responsible for keeping these records (ie, CRTs or DHMTs or both) and the depth of information to be recorded and who is synthesising all collected data has proved to be challenging. Our response to this challenge is to be guided by the DHMT preferences in relation to the format of a diary, ensure the link with existing planning and decision processes within the districts and utilise CRTs-DHMT visits to support and encourage reflection by the DHMTs on the processes.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ol\u003E\n\u003Cp id=\u0022p-87\u0022\u003EDespite the above challenges, the research team has found the DHMTs to be enthusiastic about their work and dedicated to the project and its AR approach. This positive attitude is an important catalyst in projects like this one where there is little financial incentive for the DHMTs to participate in the project. Also, there is a growing level of collaboration across the participating districts in each country\u2014and collaboration and sharing of experiences and research skills across the countries through the research partners.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section conclusions\u0022 id=\u0022sec-24\u0022\u003E\n\u003Ch2\u003EConclusion\u003C\/h2\u003E\n\u003Cp id=\u0022p-88\u0022\u003EThis paper presents the methodology for the PERFORM project, an AR-based study being undertaken in three African countries. We share five broad challenges encountered in, and the corresponding lessons learnt from, the development of the methodology: dealing with the changing context in each study site, competing priorities of the DHMTs, the complexity of this multisite study, facilitating and recording learning and processes during the project and the ethical issues.\u003C\/p\u003E\n\u003Cp id=\u0022p-89\u0022\u003EThe dissemination of this research protocol is intended to generate interest in the PERFORM project and, more importantly, stimulate discussion on the use of AR in complex studies such as this project on strengthening district health management to improve health workforce performance.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section ack\u0022 id=\u0022ack-1\u0022\u003E\u003Ch2\u003EAcknowledgments\u003C\/h2\u003E\n\u003Cp id=\u0022p-90\u0022\u003EThis document is an output from the PERFORM project: improving health workforce performance in Ghana, Tanzania and Uganda, funded by the European Commission. The project involved a consortium of six partners: Liverpool School of Tropical Medicine, University of Leeds, University of Ghana, Swiss Tropical and Public Health Institute, Institute of Development Studies, University of Dar-es-salaam, School of Public Health, Makerere University.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2\u003EReferences\u003C\/h2\u003E\u003Col class=\u0022cit-list\u0022\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-1-1\u0022 title=\u0022View reference 1 in text\u0022 id=\u0022ref-1\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.1\u0022 data-doi=\u002210.1016\/S0140-6736(04)16987-0\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan 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class=\u0022cit-fpage\u0022\u003Eiv20\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E31\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DHealth%2BPolicy%2BPlann%26rft_id%253Dinfo%253Adoi%252F10.1093%252Fheapol%252Fczs083%26rft_id%253Dinfo%253Apmid%252F23014150%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/ijlink\/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiaGVhcG9sIjtzOjU6InJlc2lkIjtzOjE1OiIyNy9zdXBwbF80L2l2MjAiO3M6NDoiYXRvbSI7czoyNToiL2Jtam9wZW4vMy84L2UwMDM2MjUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-ijlink\u0022\u003E\u003Cspan\u003E\u003Cspan class=\u0022cit-reflinks-abstract\u0022\u003EAbstract\u003C\/span\u003E\u003Cspan class=\u0022cit-sep cit-reflinks-variant-name-sep\u0022\u003E\/\u003C\/span\u003E\u003Cspan class=\u0022cit-reflinks-full-text\u0022\u003E\u003Cspan class=\u0022free-full-text\u0022\u003EFREE \u003C\/span\u003EFull Text\u003C\/span\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-11-1\u0022 title=\u0022View reference 11 in text\u0022 id=\u0022ref-11\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.11\u0022 data-doi=\u002210.1093\/heapol\/czs086\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EAdam\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ET\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHsu\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJ\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EDe Savigny\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ED\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EEvaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions?\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EHealth Policy Plann\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2012\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E27\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003Eiv9\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E19\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DHealth%2BPolicy%2BPlann%26rft_id%253Dinfo%253Adoi%252F10.1093%252Fheapol%252Fczs086%26rft_id%253Dinfo%253Apmid%252F23014156%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/ijlink\/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiaGVhcG9sIjtzOjU6InJlc2lkIjtzOjE0OiIyNy9zdXBwbF80L2l2OSI7czo0OiJhdG9tIjtzOjI1OiIvYm1qb3Blbi8zLzgvZTAwMzYyNS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-ijlink\u0022\u003E\u003Cspan\u003E\u003Cspan class=\u0022cit-reflinks-abstract\u0022\u003EAbstract\u003C\/span\u003E\u003Cspan class=\u0022cit-sep cit-reflinks-variant-name-sep\u0022\u003E\/\u003C\/span\u003E\u003Cspan class=\u0022cit-reflinks-full-text\u0022\u003E\u003Cspan class=\u0022free-full-text\u0022\u003EFREE \u003C\/span\u003EFull Text\u003C\/span\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-12-1\u0022 title=\u0022View reference 12 in text\u0022 id=\u0022ref-12\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-book\u0022 id=\u0022cit-3.8.e003625.12\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EPawson\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ER\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EGreenhalgh\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ET\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHarvey\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EG\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-source\u0022\u003ERealist synthesis: an introduction. Research methods\u003C\/span\u003E. \u003Cspan class=\u0022cit-publ-loc\u0022\u003EManchester\u003C\/span\u003E: \u003Cspan class=\u0022cit-publ-name\u0022\u003EESRC Research Methods Programme\u003C\/span\u003E, \u003Cspan class=\u0022cit-pub-date\u0022\u003E2004\u003C\/span\u003E. \u003Cspan class=\u0022cit-comment\u0022\u003EContract No.: 2\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-13-1\u0022 title=\u0022View reference 13 in text\u0022 id=\u0022ref-13\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.13\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EDieleman\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EM\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EGerretsen\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EB\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EVan der Wilt\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EG\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EHuman resource management interventions to improve health workers\u2019 performance in low and middle income countries: a realist review\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EHealth Res Policy Syst\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2009\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E7\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E7\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.stitle%253DHealth%2BRes%2BPolicy%2BSyst%26rft.aulast%253DDieleman%26rft.auinit1%253DM.%26rft.volume%253D7%26rft.spage%253D7%26rft.epage%253D7%26rft.atitle%253DHuman%2Bresource%2Bmanagement%2Binterventions%2Bto%2Bimprove%2Bhealth%2Bworkers%2527%2Bperformance%2Bin%2Blow%2Band%2Bmiddle%2Bincome%2Bcountries%253A%2Ba%2Brealist%2Breview.%26rft_id%253Dinfo%253Apmid%252F19374734%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=19374734\u0026amp;link_type=MED\u0026amp;atom=%2Fbmjopen%2F3%2F8%2Fe003625.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-14-1\u0022 title=\u0022View reference 14 in text\u0022 id=\u0022ref-14\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.14\u0022 data-doi=\u002210.1016\/S0140-6736(05)67028-6\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ERowe\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EAK\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EDe Savigny\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ED\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ELanata\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ECF\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EHow can we achieve and maintain high-quality performance of health workers in low-resource settings?\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003ELancet\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2005\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E366\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E1026\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E35\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DLancet%26rft.stitle%253DLancet%26rft.aulast%253DRowe%26rft.auinit1%253DA.%2BK.%26rft.volume%253D366%26rft.issue%253D9490%26rft.spage%253D1026%26rft.epage%253D1035%26rft.atitle%253DHow%2Bcan%2Bwe%2Bachieve%2Band%2Bmaintain%2Bhigh-quality%2Bperformance%2Bof%2Bhealth%2Bworkers%2Bin%2Blow-resource%2Bsettings%253F%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0140-6736%252805%252967028-6%26rft_id%253Dinfo%253Apmid%252F16168785%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1016\/S0140-6736(05)67028-6\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=16168785\u0026amp;link_type=MED\u0026amp;atom=%2Fbmjopen%2F3%2F8%2Fe003625.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000231955900038\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-15-1\u0022 title=\u0022View reference 15 in text\u0022 id=\u0022ref-15\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.15\u0022 data-doi=\u002210.1177\/001979399504800201\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EMacduffie\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJP\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EHuman resource bundles and manufacturing performance: organisational logic and flexible production systems in the world auto industry\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EInd Labor Relat Rev\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E1995\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E48\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E197\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E221\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DILR%2BReview%26rft.stitle%253DILR%2BReview%26rft.issn%253D0019-7939%26rft.aulast%253DMacduffie%26rft.auinit1%253DJ.%2BP.%26rft.volume%253D48%26rft.issue%253D2%26rft.spage%253D197%26rft.epage%253D221%26rft.atitle%253DHuman%2BResource%2BBundles%2Band%2BManufacturing%2BPerformance%253A%2BOrganizational%2BLogic%2Band%2BFlexible%2BProduction%2BSystems%2Bin%2Bthe%2BWorld%2BAuto%2BIndustry%26rft_id%253Dinfo%253Adoi%252F10.1177%252F001979399504800201%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/ijlink\/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToic3BpbHIiO3M6NToicmVzaWQiO3M6ODoiNDgvMi8xOTciO3M6NDoiYXRvbSI7czoyNToiL2Jtam9wZW4vMy84L2UwMDM2MjUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-ijlink\u0022\u003E\u003Cspan\u003E\u003Cspan class=\u0022cit-reflinks-abstract\u0022\u003EAbstract\u003C\/span\u003E\u003Cspan class=\u0022cit-sep cit-reflinks-variant-name-sep\u0022\u003E\/\u003C\/span\u003E\u003Cspan class=\u0022cit-reflinks-full-text\u0022\u003E\u003Cspan class=\u0022free-full-text\u0022\u003EFREE \u003C\/span\u003EFull Text\u003C\/span\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-15-1\u0022 title=\u0022View reference 16 in text\u0022 id=\u0022ref-16\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.16\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EE Cunha\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ERC\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EE Cunha\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EMP\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EImpact of strategy, strength of the HRM system and HRM bundles on organizational performance\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EProbl Perspect Manage\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2009\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E7\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E57\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E69\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DProbl%2BPerspect%2BManage%26rft.volume%253D7%26rft.spage%253D57%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-15-1\u0022 title=\u0022View reference 17 in text\u0022 id=\u0022ref-17\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.17\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EBuchan\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJ\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EWhat difference does (good) HRM make\u003C\/span\u003E? \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EHum Resour Health\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2004\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E2\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E6\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.stitle%253DHum%2BResour%2BHealth%26rft.aulast%253DBuchan%26rft.auinit1%253DJ.%26rft.volume%253D2%26rft.issue%253D1%26rft.spage%253D6%26rft.epage%253D6%26rft.atitle%253DWhat%2Bdifference%2Bdoes%2B%2528%2522good%2522%2529%2BHRM%2Bmake%253F%26rft_id%253Dinfo%253Apmid%252F15182378%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=15182378\u0026amp;link_type=MED\u0026amp;atom=%2Fbmjopen%2F3%2F8%2Fe003625.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-18-1\u0022 title=\u0022View reference 18 in text\u0022 id=\u0022ref-18\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.18\u0022 data-doi=\u002210.1093\/heapol\/17.1.14\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EBossert\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ETJ\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EBeauvais\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJC\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EDecentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EHealth Policy Plann\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2002\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E17\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E14\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E31\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DHealth%2BPolicy%2Band%2BPlanning%26rft.stitle%253DHealth%2BPolicy%2BPlan%26rft.issn%253D0268-1080%26rft.aulast%253DBossert%26rft.auinit1%253DT.%2BJ%26rft.volume%253D17%26rft.issue%253D1%26rft.spage%253D14%26rft.epage%253D31%26rft.atitle%253DDecentralization%2Bof%2Bhealth%2Bsystems%2Bin%2BGhana%252C%2BZambia%252C%2BUganda%2Band%2Bthe%2BPhilippines%253A%2Ba%2Bcomparative%2Banalysis%2Bof%2Bdecision%2Bspace%26rft_id%253Dinfo%253Adoi%252F10.1093%252Fheapol%252F17.1.14%26rft_id%253Dinfo%253Apmid%252F11861583%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/ijlink\/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiaGVhcG9sIjtzOjU6InJlc2lkIjtzOjc6IjE3LzEvMTQiO3M6NDoiYXRvbSI7czoyNToiL2Jtam9wZW4vMy84L2UwMDM2MjUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-ijlink\u0022\u003E\u003Cspan\u003E\u003Cspan class=\u0022cit-reflinks-abstract\u0022\u003EAbstract\u003C\/span\u003E\u003Cspan class=\u0022cit-sep cit-reflinks-variant-name-sep\u0022\u003E\/\u003C\/span\u003E\u003Cspan class=\u0022cit-reflinks-full-text\u0022\u003E\u003Cspan class=\u0022free-full-text\u0022\u003EFREE \u003C\/span\u003EFull Text\u003C\/span\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-19-1\u0022 title=\u0022View reference 19 in text\u0022 id=\u0022ref-19\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-3.8.e003625.19\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ELoewenson\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ER\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EFlores\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EW\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EShukla\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EA\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003ERaising the profile of participatory action research at the 2010 Global Symposium on Health Systems Research\u003C\/span\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EMEDICC Rev\u003C\/abbr\u003E \u003Cspan class=\u0022cit-pub-date\u0022\u003E2011\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E13\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E35\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E8\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DMEDICC%2BRev%26rft.volume%253D13%26rft.spage%253D35%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000293803700009\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-20-1\u0022 title=\u0022View reference 20 in text\u0022 id=\u0022ref-20\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-book\u0022 id=\u0022cit-3.8.e003625.20\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EReason\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EP\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EBradbury\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EH\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-source\u0022\u003EHandbook of action research: participative inquiry and practice\u003C\/span\u003E. \u003Cspan class=\u0022cit-edition\u0022\u003E2nd edn\u003C\/span\u003E. \u003Cspan class=\u0022cit-publ-loc\u0022\u003ELondon\u003C\/span\u003E: \u003Cspan class=\u0022cit-publ-name\u0022\u003ESage\u003C\/span\u003E, \u003Cspan class=\u0022cit-pub-date\u0022\u003E2001\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-21-1\u0022 title=\u0022View reference 21 in text\u0022 id=\u0022ref-21\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-book\u0022 id=\u0022cit-3.8.e003625.21\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EArgyris\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EC\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ESch\u00f6n\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ED\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-source\u0022\u003EOrganizational learning: a theory of action perspective\u003C\/span\u003E. \u003Cspan class=\u0022cit-publ-loc\u0022\u003EReading, MA\u003C\/span\u003E: \u003Cspan class=\u0022cit-publ-name\u0022\u003EAddison-Wesley\u003C\/span\u003E, \u003Cspan class=\u0022cit-pub-date\u0022\u003E1978\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-22-1\u0022 title=\u0022View reference 22 in text\u0022 id=\u0022ref-22\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-book\u0022 id=\u0022cit-3.8.e003625.22\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022duplicate\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EMaccoby\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EEE\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ENewcomb\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ETM\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHartley\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EEI\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ELewin\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EK\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EGroup decisions and social change\u003C\/span\u003E. In: \u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EMaccoby\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EEE\u003C\/span\u003E\u003C\/span\u003E, \u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ENewcomb\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ETM\u003C\/span\u003E\u003C\/span\u003E, \u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHartley\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EEI\u003C\/span\u003E\u003C\/span\u003E, \u003Cspan class=\u0022cit-edition\u0022\u003Eeds\u003C\/span\u003E. \u003Cspan class=\u0022cit-source\u0022\u003EReadings in social psychology\u003C\/span\u003E. \u003Cspan class=\u0022cit-publ-loc\u0022\u003ENew York\u003C\/span\u003E: \u003Cspan class=\u0022cit-publ-name\u0022\u003EHolt, Rhinehart and Winston\u003C\/span\u003E, \u003Cspan class=\u0022cit-pub-date\u0022\u003E1958\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E197\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E211\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-23-1\u0022 title=\u0022View reference 23 in text\u0022 id=\u0022ref-23\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-book\u0022 id=\u0022cit-3.8.e003625.23\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-ed-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHart\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EE\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EBond\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EM\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. eds \u003Cspan class=\u0022cit-source\u0022\u003EAction research for health social care: a guide to practice\u003C\/span\u003E. \u003Cspan class=\u0022cit-publ-loc\u0022\u003EBuckingham\u003C\/span\u003E: \u003Cspan class=\u0022cit-publ-name\u0022\u003EOpen University Press\u003C\/span\u003E, \u003Cspan class=\u0022cit-pub-date\u0022\u003E1995\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022https:\/\/bmjopen.bmj.com\/content\/3\/8\/e003625.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Abstract\u003C\/a\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup footnotes\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 class=\u0022section fn-group\u0022 id=\u0022fn-group-1\u0022\u003E\u003Ch2\u003EFootnotes\u003C\/h2\u003E\u003Cul\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-1\u0022\u003E\n\n\u003Cp id=\u0022p-91\u0022\u003E\u003Cspan class=\u0022fn-label\u0022\u003EContributors\u003C\/span\u003E RH, TM, MA, SOB, PK and TMa are the principal investigators on the grant and made substantial contributions to the conception and design of the project. CM wrote the first draft of the present manuscript and updated further drafts based on feedback from the coauthors. All authors reviewed and commented on the first and subsequent drafts of the manuscript. All authors read and approved the final manuscript.\u003C\/p\u003E\u003C\/li\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-2\u0022\u003E\n\n\u003Cp id=\u0022p-92\u0022\u003E\u003Cspan class=\u0022fn-label\u0022\u003EFunding\u003C\/span\u003E This study is funded by the European Commission Seventh Framework programme (FP7 Theme Health: 2010.3.4-1, grant agreement number 266\u2005334).\u003C\/p\u003E\u003C\/li\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-3\u0022\u003E\n\n\u003Cp id=\u0022p-93\u0022\u003E\u003Cspan class=\u0022fn-label\u0022\u003ECompeting interests\u003C\/span\u003E None.\u003C\/p\u003E\u003C\/li\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-4\u0022\u003E\n\n\u003Cp id=\u0022p-94\u0022\u003E\u003Cspan class=\u0022fn-label\u0022\u003EEthics approval\u003C\/span\u003E Faculty of Medicine and Health Research Ethics Committee, University of Leeds (Ref: HSLTLM\/11\/053).\u003C\/p\u003E\u003C\/li\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-5\u0022\u003E\n\n\u003Cp id=\u0022p-95\u0022\u003E\u003Cspan class=\u0022fn-label\u0022\u003EProvenance and peer review\u003C\/span\u003E Not commissioned; internally peer reviewed.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-custom pane-2\u0022 \u003E\n \n \u003Ch2 class=\u0022pane-title\u0022\u003ERequest Permissions\u003C\/h2\u003E\n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cp\u003EIf you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center\u0026rsquo;s RightsLink service. 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